TennCare rating system draws fire during hearing

Dec. 20, 2013

Carol Westlake, the executive director of the Tennessee Disability Coalition

Written by

The Tennessean

Patti Killingsworth

A TennCare process for deciding who qualifies for nursing home care came under fire at a legislative hearing Thursday when people complained about a program called Choices creating barriers.

Choices gave families the option of deciding whether to put a loved one in a nursing home or get state assistance to provide at-home care when it was launched in 2010, but the program has evolved. Last year, it launched a new rating score for determining who qualifies for skilled nursing care. That system rates people according to deficiencies of daily living, such as whether they are able to walk or feed themselves. People are falling through the gaps because the scoring system is flawed, according to testimony before the Senate Health and Welfare Subcommittee.

Carol Westlake, the executive director of the Tennessee Disability Coalition, told about the plight of a Jackson man denied a nursing home slot even though he was paralyzed on one side from a stroke, in a wheelchair and unable to give himself insulin shots to control diabetes.

She said the new evaluation system and appeals process create lengthy delays for families when they are desperate for help.

“You need a process that works efficiently and effectively at the moment in which you need that,” Westlake said.

People who have been living in assisted-care facilities are being told to leave because they need a greater level of care, but the state is denying them access to nursing homes, Westlake said.

Patti Killingsworth, an assistant commissioner with TennCare, said the bureau is working to address the concerns raised.

“The value of today is that we are able to hear some specific recommendations and ideas about things we can do to improve the process,” she said after the hearing. “We are always looking for those. I’ve made a commitment both to the people who presented that testimony and to the chairman that we are going to sit down and evaluate those things as we do on a constant basis and figure out if there are improvements that can be made either in the criteria or the process.”

Since the launch of Choices, the number of people in home- or community-based care other than nursing homes has risen from 5,000 to 13,000, Killingsworth said in her testimony.

The cost can be half or a quarter less than the expense of nursing home care, she said.

“While 40 percent of our members are now receiving their services in home- and community-based settings, we still spend roughly 80 percent of the funding on institutional care,” Killingsworth said.

Scoring system

For years, Tennessee’s Medicaid program would provide nursing home care to patients with just one daily living deficiency, she said. Anyone who scores 9 on a scale of zero to 26 qualifies for nursing home care and coverage under TennCare. The bureau does make exceptions for people who score less but still need more comprehensive services, she said.

TennCare has nurses who score the patients because there is an inherent conflict for nursing homes to make that determination, she said.

Sen. Doug Overbey, R-Maryville, pointed out that the issue involved more than nursing homes.

“I think a more accurate statement is the family members of the patient want the patient to qualify,” he said. And he added that families are encountering an appeals process that can linger for several months.

Julie Griffin, who is a lobbyist for the Tennessee Medical Association, attended the hearing even though the nursing home issue did not directly involve doctors. She said she was there representing herself and her mother.

“I’ve been taking care of my mom for 25 years,” Griffin said. “It got to a point where I couldn’t do it any more. She is OK now thankfully to two legislators who brought the right people together. If it had not been for that, I don’t know that my mother would have the services she needs. She couldn’t get out of bed. She couldn’t keep herself clean. She couldn’t get herself to the bathroom. Yet I could only get enough services for somebody to come by a couple of times a week to give her a bath.”

However, the Choices program is still valued for its original concept. Denise Cole, the caregiver to a 22-year-old son who suffered a brain injury in a car wreck last year, told the subcommittee about her family’s gratitude for the program.

“His speech is very limited but one day while we were watching a Braves game, he looked at me and said, ‘Home,’ ” she said. “I said, ‘OK, buddy, we will do everything we can to get you home.’ So we met with a Choices representative who started the process and we came home on Sept. 13 after 10 months away from home. That has been such a blessing to our family. It has made a huge difference with Austin. He has a long way to go, but we have come a long way too.”